Therapy with Tough Clients: Exploring the Use of Indirect and Unconscious Techniques

By George Gafner

Whether you're fairly new to therapy or you've practiced for many years, no doubt at times you've found yourself stumped with certain clients who leave you feeling perplexed and discouraged with that 'I-just-don't-know-what-to-do-next' feeling. George Gafner has been there and that's precisely why he wrote this book. The reality is that today's cookie-cutter treatment mentality presupposes that all people with, say, depression, can be treated essentially the same way, which virtually ignores the established fact that a good deal of a person's mental functioning is governed not by conscious choice but instead by automatic, or unconscious, forces that lie outside voluntary control

• Language: English
• Publisher: Crown House Publishing
• Release date: Jan 8, 2014
• ISBN: 9781845908836

George Gafner

George Gafner, MSW, LCSW, is director of the hypnosis training program and director of the family therapy training program at the Southern Arizona Veterans Affairs Health Care System, Tucson. He is the author of four previous books on hypnosis and hypnotic inductions.

Book preview

Praise for Therapy with Tough Clients

As Gafner takes the reader through the therapy of two of his most challenging clients, he presents what he calls directed unconscious therapy and often transcends the translucent membrane between hypnosis and non-hypnotic therapy. This book is intended as a hand-son resource and is replete with clinical wisdom. Wonderful-Serious-Wise, this is the work of a true master, Therapy with Tough Clients should be required reading for all entry level therapists and most seasoned therapists as well.

Stephen R. Lankton, MSW,

author of Tools of Intention

Therapy with Tough Clients was primarily written to be of help to the clinician by offering a variety of approaches to treating challenging cases. But the book does much more than this: Gafner challenges us to recognize and transcend our own limitations, encouraging a personal growth that will no doubt spill into performing more creative and effective psychotherapies. Read this book and you will be better in more ways than one!

Michael D. Yapko, Ph.D., author of

Trancework and Depression is Contagious

When searching the bookshelves it is evident that there is virtually no literature available devoted to exploring the tricky subject of handling challenging clients, especially from a hypnotherapy perspective. Not afraid to meet this difficult aspect of the therapeutic relationship head on, George Gafner has written a thought-provoking book that admirably fills this glaring void. Espousing a refreshing pluralistic approach to therapy he explores working with overt and covert resistance, whilst openly discussing the often taboo subject of the therapist’s personal cognitive and emotional reactions.

One of the many highlights of this engaging book is that approaches are illustrated through on-going case studies, which are constructively dissected, affording the reader the opportunity to fully get to grips with every nuance. Ostensibly based around PTSD, there is much to learn for those not versed in the treatment of trauma as each approach is adaptable to any client that presents a challenge to the therapeutic process.

Gaffner is an expert in therapeutic story telling and therefore this book is unashamedly based around metaphor. That said, other aspects of hypnotherapy, including the use of paradox, are effectively demonstrated in situ in the abundant therapy transcripts. The author also includes informative discussions on the potentials and pitfalls of using cultural metaphors, whilst reviewing hypnotic language and hypnotic phenomena for those new to hypnotherapy. With therapists from every background in mind, the author discusses how approaches can be applied both hypnotically and non-hypnotically. He also explores their application in a diverse range of settings, from couples therapy to those working with people held in correctional facilities.

This is a well-rounded book that holds something for everyone, irrespective of their therapeutic background.

Peter Mabbutt FBSCH, CEO/Director of Studies London College of Clinical Hypnosis

Fans of Milton Erickson and his work with metaphors will love George Gafner’s new book, Therapy with Tough Clients. From the very beginning, it is obvious that the author has mastered the use of metaphors as he discusses different categories of metaphors: darkness, weight, captor, and descent. In addition, he refers to overused metaphors as well as misunderstood cultural metaphors and he also listens to his clients’ metaphors even before the hypnotic experience begins.

The book focuses on two case histories, Maggie and Charles, both veterans who are suffering from a number of problems since their return from combat. They are introduced in the first chapter, and we get to follow their progress throughout the book, but the book is not limited to only Maggie and Charles. One interesting case was how he successfully handled a potentially volatile situation when an angry spouse burst into the middle of her husband’s session.

Although the book is filled with various metaphors, the author also believes in the value of ego strengthening, and devotes an entire chapter emphasizing it. At the same time, he shows his human side by sharing a couple of ooops comments to let us know that he also makes mistakes. Gafner says, therapy is more of an art than science, and I totally agree. It is obvious that he is a master of the artistic use of metaphors in therapy, and his book is easy to read.

Roy Hunter, FAPHP, DIMDHA,

author of The Art of Hypnotherapy

George Gafner is a seasoned clinician who provides a variety of creative ways to use hypnotic procedures and storytelling to treat diverse clients. He uses case vignettes effectively to illustrate the process of therapeutic decision-making. Anyone who is a follower of the Milton Erickson mode of intervention will find this book engaging and informative.

Donald Meichenbaum, Ph.D., Distinguished Professor Emeritus, University of Waterloo, Ontario, Canada and Research Director of the Melissa Institute for Violence Prevention, Miami, Florida

George Gafner has devoted his professional career to refining his approach to hypnosis to benefit the clients with whom he worked. This book provides a distillation of years of exploration, study, and clinical practice that George shares with us in an engaging and highly readable manner. He presents interesting and complex cases and aptly demonstrates how hypnosis is often the treatment of choice due to the wide variety of options it provides. The book is clear and comprehensive, insightful and illustrative. Readers will find a depth of knowledge and analysis in these pages that will stimulate valuable ideas that can be utilized in their own work.

Brent B. Geary, Ph.D., co-editor of

The Handbook of Ericksonian Psychotherapy

THERAPY WITH

TOUGH CLIENTS

The Use of Indirect and Unconscious Techniques

George Gafner, MSW, LCSW

To Sam Atterbury

Foreword

George Gafner is a storyteller and all of his clients know this. It is not unusual for his clients to ask him to tell them stories during a session. He is also a hypnotist, and has had many years of experience as a therapist. Storytelling and hypnosis seem to go seamlessly together for him (as they do for me). When the story is sufficiently engaging the listener goes into a kind of reverie state, there is focused attention, and most therapists would recognize that their client is in what can be described as a natural everyday trance. This interaction between therapist and client is comfortable and provides a useful instantaneous rapport. What better way for a therapist to help a client work through difficulties?

George has worked with many clients during his professional career in institutional settings such as the Veterans Administration (V.A.) system and jails. These settings and clients are amongst the most difficult to help with psychotherapy. Many of the veterans have PTSD; prisoners and others in institutional settings may be sociopathic and abuse themselves with drugs and alcohol. Yet, somehow, stories and the metaphors embedded within them are so universal that they become the royal road to establish a productive therapeutic alliance. People appear to be more receptive to suggestions when listening to stories. In that sense the therapist is communicating directly with the client’s unconscious or inner mind. The more possibilities the therapist builds into the story, the more likely it will be that the listener will latch onto one or more of the embedded suggestions, and use them to reframe themselves out of their stuckness. George is well aware of this, and especially the need to put into the storytelling sufficient pauses so that the listener can process information in his/her own unique way. He also understands that in the interpersonal interaction time in his office that he has to be himself and from time to time share some personal things. (The latter, of course, is done cautiously and with conscious design!)

In this volume, there are many clients whose concerns are discussed in detail. They illustrate George’s experience in working with a diverse population and the ways he chooses to help them. As a kind of leitmotif he focuses on two clients—Maggie and Charles—who appear repeatedly in the book. Most therapists would regard them as being difficult to work with, and George illustrates this in detail, including his own mistakes. He worries about these sessions and mistakes, and we all learn along with him as he freely lets us participate in his progress with Maggie and Charles. It is almost like looking over his shoulder as he ponders what to do next—stories seem to come to the rescue time after time! And he is not afraid to be directive from time to time.

This book is strewn throughout with gems of wisdom and practical things to do, and it is well worthwhile studying. As an added bonus, Chapter 14 contains a number of useful story transcripts which can be adapted to many different circumstances.

Rubin Battino, MS

Yellow Springs, OH

Contents

Title Page

Dedication

Foreword by Rubin Battino

Introduction

Chapter 1. Initial sessions with Maggie and Charles

The Case of Maggie: a referral for individual therapy

Pandora’s Box

Notes for practice

The Case of Charles, another referral for individual therapy

The Three Lessons

Notes for practice

Chapter 2. Metaphor, story and other invaluable devices

Cultural issues: Missing the point

Research on metaphor

Metaphorical examples

Metaphors for depression

Hackneyed metaphors and Easy Street

Concrete metaphors

The Story and the anecdote

Hypnotic language

Hypnotic phenomena and elegant indirect techniques

Time distortion

Amnesia

Dissociation

Catalepsy

Taking advantage of hypnotic phenomena in the session

Integration through discussion?

Moments of dissociation in a session

Embedded suggestion

The Wok

Waterfalls and enormous soft drinks

Security anecdote

Balloons everywhere

Tony’s Balloons

Frankie’s Balloons

Seeding

Sound seed and split suggestion

Misspeak

Interspersal—another elegant indirect technique

Indications for use

Chapter 3. Irritable bowel syndrome (IBS) and continued therapy with Maggie and Charles

Irritable bowel syndrome

Healing stories

White sand beach (Benson, 2011)

The Molasses Reef story

IBS-specific anecdotes

The Burglary

The Great Vowel Shift

Notes for practice

Charles’ second session

The Garden, a story by Charles

Notes for practice

Chapter 4. Ego-strengthening

Albert Bandura

Direction versus indirection within hypnosis

Many tools in the toolbox

I need to know I ‘went under’

Influence of Erickson

Ego-strengthening within hypnosis

Improvement with ego-strengthening alone

But didn’t Mussolini make the trains run on time?

Different people, different conclusions

Ego-strengthening outside of hypnosis

Group anger management

Conveying suggestions

Major ego-strengthening techniques

Story, anecdote and short-burst

The Greenhouse

Anecdotes

245 Feet High

Lodgepole Pine

Strong cactus

Matchstick girl

Short-burst ego-strengthening

Mixing techniques in a session?

Don’t forget Albert Bandura

Chapter 5. Maggie and Charles continued

The Case of Maggie

Recent losses

Making sense of it all

Earlier life—and a detour

A night at PP’s

Notes for practice

The case of Charles

Automatic writing

Notes for practice

Chapter 6. Perturbation and pattern interruption

Stirring the soup

Perturbation in daily life

Perturbation with new clients

Say uncle in the ante room, write in the drawing room, or go far in the waiting room

Generating an evergreen epiphany

Patterns in daily life

Pathologic routines

The case of Kathryn

The Rationale

Were the target something else

Sequencing

Other ways to perturb

Pills story

Instigative anecdotes

Robert Frost

Rings in a Dream

The Shipworm

Painting Landscapes

Amplifying the metaphor technique

Let’s see how Dr. Tracten gets traction with this technique

Amplifying both metaphors

Notes for practice

Fish again

Recovered memories

Earl the Pearl

Chapter 7. Maggie and Charles are back

Case of Maggie

Alternating Stories: The Good Spirit and Simple Rooms

The Good Spirit

Simple Rooms

(The Good Spirit concluded)

Notes for practice

The case of Charles continues

Charles’ wife bursts into the session

Pineapple anecdote

Notes for practice

Slot Canyon story

Instigative anecdotes (Gafner, 2004)

Helen Keller

Labyrinth

After the Pond

Post-It Notes

Mark Twain

Chapter 8. PTSD and war

Persian Gulf War (383 U.S. Dead)

Barriers to treatment

PTSD treatment in the V.A.

World War I (116,000 U.S. Dead)

World War II (405,000 U.S. Dead), Korea (92,000) and Vietnam (58,000)

Vietnam War

Help from medication

Substance abuse

Psychotherapy and PTSD

Intrusive images

EMDR and cognitive-behavioral therapy (CBT)

Trauma-focused psychotherapy is practiced world-wide

Watching part of a movie over and over again

EMDR

Culture and EMDR

Current V.A. treatment

Therapy as we know it may not be for everyone

Finding help in affinity

The Performative

In conclusion

Chapter 9. Using story techniques

Alternating stories with Maggie

Charles and Bernadette

Active role of the therapist

What needs to happen with couples early on

Patrick’s relationship

Couple dynamics and marital therapy

Couples and themes

Back with Charles and Bernadette

Cactus story

Two days later Charles is back

Road 302 story

Tyranny of Ten story

Notes for practice

Story techniques

A story for a 64-year old man with heart failure

Storm Clouds story

Adding on with a behavior prescription

Unethical treatment?

Anecdote within a story

The Playing Field story

It can be continuous, mutual, without an ending, or within a story

Mutual storytelling technique

Story without an ending

Chapter 10. A curse and the Greek chorus amidst continued therapy

Maggie returns and her mother reveals the curse

Notes for practice

Dora and Antonio

Fausto and Carmen

Charles and Bernadette are back

The Pond

Charles returns by himself

Greek Chorus

Notes for practice

Chapter 11. Therapy nears its conclusion

Maggie is back

Charles’ surprise visit

Notes for practice

Chapter 12. Farewell to Maggie and Charles

Maggie’s priest

Father Sean visits the V.A. a week later

Finishing up with Maggie

Seeing Things Differently

Maggie’s therapy is concluded

Bernadette leaves a phone message

Chapter 13. Employing indirect techniques in various treatment settings, and more

Other indirect techniques

Confederate outside the door

Rustling some papers

An unconventional story application: Strange but true

Can chickens be incorporated into a treatment plan?

Back to the basics with a story

Hypnotic techniques in hospitals, residential treatment, and correctional facilities

Ramon the screamer

Young Indian woman

Milling around

I need my meds now!

Offal in the shower

Enter the tweakers

93-year-old pedophile

I deserve to die

Blind and deaf

Maybe I’m interested

Tomato story

Organized crime

Another view behind bars

Generating your own material

Balloons may have been a fantasy

Refining your therapeutic voice

What is a good hypnotic voice?

A good hypnotic voice goes with the client

Contrasts are your friend

Your voice in a story and other scripts

Chapter 14. Favorite inductions and stories

Story inductions

Glen Canyon induction

Rumination Induction (for insomnia)

The Magic Theater: A guided imagery induction

Ego-strengthening stories

The Maple Tree

The Little Cactus

The Lighthouse

The Balloons

Instigative stories

African Violets

Pauly the Pufferfish

Silver Fox

Eating Dirt

In the Freezer

Glossary of Terms

References

For Further Training and Reading

Index

Copyright

Introduction

An enduring teachable moment

When we do unconsciously-directed work with clients we are privileged, as they open for us that window to the deepest part of them. When we direct therapy through that window—with story, anecdote, hypnotic language, pacing of ongoing response, or various other techniques—I call this an enduring teachable moment, as it is a time of heightened receptivity. But this is not a one-way glass like we used in the 1970s to view trainees doing therapy. We, as therapists, also have an ongoing process, much of it unconscious, reflected back through that window, and in this book I try to capture both sides of that window as I take you through therapy with two engaging and multidimensional people, Maggie and Charles. They represent two of the most complicated and challenging clients I ever had, and by working with them I demonstrate a host of techniques that you may find useful in doing therapy with your toughest clients.

Once I heard someone say that a delight in poetry is discovering something I didn’t know I knew. Now, recalling that discovery is an example of this enduring teachable moment, and I’d bet that whatever that person read that day in a poem continues to sit there deep within, waiting to be triggered in the future by a like association. So, too, an enduring teachable moment is evident when I run into a client I saw 15 years ago and she mentions, You know, that old woman in the woods you told me about, I still think about her. Something triggers the memory of the woman in the story. It may be mention of a cold day, a forest, or of some other aspect of The Three Lessons story she heard from me years ago, all inextricably linked to the meta-message of the story, that people have resources within to help themselves with their problems. That memorable tale, which I adapted from a story of the same name by Lee Wallas (1985), is an example of what you can do in your practice, borrowing from a story or technique in this book, adapting it to your needs, and fashioning it for whatever clinical scenario you encounter.

Luis, back from Afghanistan

As the unconscious is certainly the aegis of hypnosis, and as this book deals in part with hypnosis, let me share a clinical example that opened up this window to me as much as the client. Around 2005, I was referred a young Hispanic soldier, Luis, who had recently returned from Afghanistan. His problem was erectile dysfunction. He was in perfect health, on no medications, did not have depression or PTSD—despite months of harrowing combat—and like many hypnosis referrals, it came out of frustration after all else had been considered. Luis was married, of average intelligence, spoke good English, and said he didn’t drink or use drugs. He was calm, in no distress whatsoever, and said he wasn’t bothered at all about the war. His only concern was that he was impotent.

The next session we began hypnosis. He responded with deep trance and amnesia to a conversational induction and The Three Lessons story, which embeds the suggestion that people have resources within to help with their problem. The next session I employed a similar procedure but added an ego-strengthening story and set up finger signals for unconscious questioning. Using age regression, I asked him to go back in time to any time in the past that might have to do with the problem … and when you’re there, Luis, you may let your ‘yes’ finger rise. After about a minute his index finger twitched and he began to mutter some words that were unintelligible to me, but I did glean a fragment of a phrase, I-U-D, I-E-D.

I re-alerted him and discussed today’s session. It soon was apparent that his unconscious mind had mixed up the improvised explosive devices (IEDs) in the war with his wife’s new intrauterine device (IUD), and impotence resulted. Discussion normalized and integrated this phenomenon, the problem immediately resolved, he was seen one more time in a month and was doing fine, end of story. Now, how many sessions of talk therapy might have been needed to resolve that problem?

Peter in jail

Therapy with Luis was during a scheduled appointment in a comfortable office at the Veterans Affairs (V.A.) Medical Center. The conditions were optimal. But such conditions aren’t always necessary to elicit a similar response within unconsciously-directed therapy. For example, I am now retired, for the most part, but I used to work about four days a month at the local jail. The other day one of the psychiatrists grabbed me as I was walking by and asked me if I would see this very anxious client I’ll call Peter, a Black male being treated for bipolar disorder. I sat with Peter for a few minutes in a busy hallway outside the exam rooms in the medical section of the jail. The first thing I noticed was Peter’s very fast and shallow breathing.

I showed him deep breathing and asked him if I could tell him a little story while he practiced this better way to breathe. You can close your eyes or keep them open, whatever you wish, I told him He chose to close his eyes and I told him The Three Lessons story, which I often use early on. People continued to walk by in handcuffs and chains, doctors and nurses were talking, and it was business as usual while Peter responded highly favorably to the story. In two minutes we were done, his anxiety was allayed, and he left with some tools to help him in the future. I have had similar responses in even worse conditions there, like talking to them through the food trap in the door in segregation, or standing in the corner of a busy day room with the curious walking by, straining to hear what was being said. In other words, a nice office with a recliner and wind chimes music is nice, but if you don’t have it, you can improvise, even in the midst of rapists and murderers.

Standing on broad shoulders

In my years in this business I have learned from many, from my family, colleagues, people in the field, and my trainees, who came from divergent backgrounds and theoretical perspectives. However, my clients probably taught me more than anyone. For 38 years I worked at clinics and hospitals, and for 28 of those years I directed a program in family therapy and hypnosis training in the V.A. in Tucson, Arizona.

I learned from people who had extraordinary experiences, like the men who had been prisoners of war in World Wars I and II, as well as in later wars in Korea and Vietnam. I learned from the reactant and hostile, like the spouses and children who involuntarily attended family therapy, or those who were directed to attend one of the two anger management groups I conducted for 20 years. One Vietnam veteran with florid PTSD said he was eager to attend because this is my 12th marriage and I intend to keep it. He did well in the group and his wife was eternally grateful. Years after the group, when I encountered that man or many others, I asked them what they remembered about the group, and invariably they answered, To take a deep breath or a time-out … but what I liked best was the stories you told. Indeed, stories and anecdotes, both indirect, or unconsciously-directed techniques, have been my allies for many years.

I learned from my long-term therapy clients and I learned from the ones I saw only once or twice, like the paranoid personality disorder who defied me to try and help him. The V.A. is a fascinating place to work because you encounter a wide diversity of people with every kind of clinical problem. The youngest veteran I saw was 19 and the oldest 102. The oldest couple I saw had been married 76 years. Their recipe for a successful marriage? Always talk things out and never go to bed angry. I learned from the elderly schizoid woman whose eyes I never saw because of her mirrored sunglasses. I learned from the overly compliant and passive, the therapy addicts who lived in their heads and were resistant to all change however small. I learned from the 200 trainees I had over the years in psychology, psychiatry, nursing, social work and other disciplines. I estimate that over the years I had to do with some 10,000 clients that I either saw directly or whose cases I supervised. In this business we quickly learn that some we help, some we don’t, and some we never know because they just fade away.

Trying new things as we counter resistance

For years on Tuesday evenings I was a volunteer therapist at the refugee clinic of the University of Arizona where I saw victims of torture. These people from Central America, Africa and the Balkans had experienced all manner of cruelty, loss and humiliation. I’ve always done therapy in either English or Spanish, but sometimes at this clinic an interpreter was employed, usually a French-speaking medical student who had done a rotation in Africa. From those in the refugee clinic I learned how fleeting and precious life is, and how we need to make the most of those few minutes or hours we are with any client. Seeing people who were able to overcome the most awful circumstances somehow made it easier for me to help the majority of my clients, people whose problems were understandably dear to them but which paled in comparison to those of survivors of the Bataan Death March, or the lone survivor in a village where all were killed.

Along the way I learned patience. With patience you don’t give up on clients and you keep trying new things in order to make an impact. As we try new approaches and techniques we discover what may work in certain situations, but we especially learn what may work for us. From these successes we build confidence, and this confidence is immediately apparent to others. I intended this book to be not only an aid to your practice, but also an impetus for the growth and development of the clinician.

Scientifically supported treatments

Currently, in many quarters there is a strong push to practice only one modality for most disorders. Of course, this means some variant of cognitive-behavioral therapy (CBT). I support CBT as a front-line approach. However, I know many seasoned psychologists and other practitioners—not only those new to the field—who disdainfully throw up their hands and are at a total loss when the client says, I already had CBT and it didn’t work, or "I believe my problem resides in my unconscious, and I want therapy directed at that. I had many clients who in the first few minutes said, Please don’t ask me to list my dysfunctional thoughts; I already did that both in group and individual therapy." So what does one do with those clients? Well, please read on.

A hands-on resource to assist with the toughest of clients

I make the assumption that you have been trained in one of the major disciplines, that maybe you are licensed, and that in your counseling or therapy practice you are guided by a generally accepted therapeutic approach. You’ve heard the saying, When you buy a new hammer everything looks like a nail. Well, I know clinicians whose average day consists of EMDR or hypnosis sessions, hammering one nail after another. I asked them, What if they have acute grief or a crisis? You guessed it, EMDR is good for everything, they know because every client looks like a nail. I’m not denigrating EMDR, as I’ve used it for many years, but almost all the time for everyone?

For you, perhaps you practice some version of CBT, or a mindfulness-based therapy, or maybe your theoretical orientation is psychodynamic, NLP, or some other popular approach. Perhaps you employ meditation or relaxation and stress management with your clients. If you could use an extra hand with your toughest clients, I encourage you to read on.

When first conceiving this book I thought, What kind of resource can best assist clinicians irrespective of their approach? As such, I intended this book to be a hands-on resource that offers you ideas, choices, and opportunities to employ as an add-on to your approach. I’m very familiar with clients who, early on, would set off alarm bells in my head, you know, where the hair on your neck stands up and your gut response is, Oh, no, not another one! With such clients, you know you have your work cut out for you and maybe you even say to yourself, They don’t pay me enough to try and help people like this, let me think … hmm, how can I ensure that they WON’T return? Believe me, I’ve thought those thoughts, but I kept them to myself, not wanting to be mean-spirited or disrespectful, and went ahead and did my best with people who were, as we say in the U.S., a sharp stick in the eye. Now, that type of client is an obvious example of a person whose resistance and overall presentation are worse than challenging. Even with them there are techniques that can help.

Building a foundation before advancing to corrective measures

With many people, the challenges are more subtle. You think therapy is progressing well and all of a sudden they start canceling, or just don’t show up. Something is operating beneath the surface—the issues are too dear, or you failed to put your finger on something important. In any event, you need to identify and rein in resistance so that therapy can move forward. For sure, I realize that there are some clients who simply aren’t ready to address vital issues. They bolt from therapy early, but hopefully they learned something from a session or two so that this foundation can propel them to successful therapy in the future.

One thing I emphasize in this book is how we can till the soil before planting the seed by building a firm base of ego-strengthening before moving on to corrective techniques. I explain this to clients as doing a mental building up first, likening it to a debilitated medical patient who requires major surgery (Hammond, 1990). That patient can first benefit from rest and good nutrition, strengthening her ahead of time. In psychotherapy, I believe that far too often the client comes in and says, I need help with this problem, and we unwittingly jump in with corrective measures. The client isn’t ready, we lose them, and once again we’re left ruminating on